LGBTQ issues across the life span

The specific biological mechanisms that underpin how people develop as lesbian, gay, bisexual, transgender, questioning or queer (LGBTQ) are still undiscovered, but what many researchers have determined is that neither sexual/affectional orientation nor gender identity is a choice. Rather, they are innate, unchangeable parts of who a person is, much like skin color.

And like people of color, LGBTQ individuals regularly encounter significant prejudice throughout their lives. This stigma can make life’s typical slings and arrows all the more painful. Although tremendous progress has been made in LGBTQ rights in the past few decades, counselors must still work to understand the barriers that these clients face across all stages of the life span.

“Growing up in any marginalized group can cause issues surrounding identity,” says Misty Ginicola, the lead editor of the new book Affirmative Counseling With LGBTQI+ People, published by the American Counseling Association. “For LGBTQI+ persons” — referring to individuals who identify as lesbian, gay, bisexual, transgender, queer, questioning, intersex, asexual, ally, pansexual/polysexual or two-spirited — “the unique identity surrounds not only who they bond with and are attracted to, but very often also their own gender identity and expression. Rather than having their differences be celebrated, unfortunately, LGBTQI+ people commonly grow up in an environment where they internalize very early on that their differences are taboo or undesirable, particularly if they grow up in a disaffirming religious context. Being marginalized also puts a person at greater risk of experiences of trauma and bias incidents, which impacts how safe a person is in any given context.”

Growing up LGBTQ

In general, experts are finding that children and adolescents are growing more comfortable with coming out at an early age, according to Ginicola, a professor of counseling and school psychology and coordinator of the clinical mental health counselor program at Southern Connecticut State University. If this coming-out process transpires in a supportive and affirmative environment, it can help LGBTQ students to form a strong sense of self and establish healthy relationships, she notes. However, in many cases, these individuals face significant stigma from an early age.

“Being LGBTQ in school requires continuous negotiations between authenticity, connection, safety and health,” explains Colton Brown, a member of the Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling (ALGBTIC), a division of ACA. “Students may find themselves in unsupportive or even hostile environments.”

ALGBTIC President Tonya Hammer notes that physical, emotional and verbal bullying of LGBTQ students begins as early as elementary school or even prekindergarten. “While physical bullying, particularly that which results in injury and at times death, is prevalent and probably the most talked about since it makes the news sometimes, the cyberbullying and the emotional and mental bullying that take place can often be just as harmful … if at times not more so,” she says.

LGBTQ individuals may be subject to bullying across the life span, but the experience of being bullied can be particularly devastating when it occurs early in a person’s life, says Hammer, an assistant professor of counseling and coordinator of the counseling program at Oklahoma State University. “The power of language and words to inflict damage — especially on children — is often dismissed,” she says.

Insults and taunts — long a staple of playgrounds and classrooms — have found an additional and often particularly vicious arena in cyberspace, warns Hammer, whose research focus includes both bullying and the intersection of gender and sexual/affectional orientation. “Cyberbullying — from Instagram to Snapchat — is only growing and, unfortunately, much harder to address and remedy,” she says. “If physical bullying takes place on school grounds, counselors, teachers and administrators have the capability to take action. However, much of cyberbullying takes place outside of their purview, as well as that of parents, and often goes unnoticed by adults.”

Transgender students are particularly at risk for bullying, stigma and rejection, says Brown, a counselor in the college clinic at the University of Central Oklahoma and a doctoral student in counseling psychology at Oklahoma State University. “Transgender students often face difficulty with coming out because their authentic selves are typically much more visible than [that of] LGBQ students,” he notes. “These students face bathroom and locker room barriers that may come from peers, teachers, administrators and even state policies.” Transgender students also may be excluded from participating in many extracurricular activities such as sports teams because of their gendered nature, he says.

Brown points out that these painful exclusions are happening during a crucial developmental period when adolescents are typically learning how to form various emotional bonds. Transgender and other LGBQ adolescents “may be looking for friendship or romance but can be met with rejection [instead],” he says.

Further complicating matters for many transgender adolescents is that they may not be able to fully establish their personal identities. Those who wish to transition medically need parental support until they are 18, Brown explains.

But transgender students are not the only members of the LGBTQ community who face unique barriers in coming out and finding community, Brown says. Bisexual youth also often find themselves struggling for acceptance and a sense of belonging, not just among heterosexual, cisgender students, but also within the greater LGBTQ community, he says.

“Bisexual people are generally defined by who they are dating at a given time,” Brown explains. “For example, if a male student is dating a female student, then [he is] assumed to be heterosexual. If that same male student is dating a male student, the script flips, and he is now considered gay. Students do not often consider that this student may actually be bisexual. These perceptions can result in these students not feeling ‘straight enough’ for the heterosexual kids or ‘gay enough’ for the gay kids.”

“Bisexual students are in this middle ground in which they may be left without a close-knit group unless they find other bisexual students,” Brown continues. “These students may also struggle more with coming out due to the continued pressure to define themselves outside of who they are or are not dating. Other students also internalize monosexist messages from adults, media and culture and may harass or discriminate against bisexual students. These factors can result in bisexual students feeling shame and may result in internalized biphobia.”

The potential rejection and lack of support may lead LGBTQ children and youth as a whole to be wary of being their authentic selves with friends, teachers, parents and counselors, Ginicola says. “They may also attempt to hide this identity from romantic partners before they have accepted their affectional orientation or come out to others,” she continues. “In this context, identity development in adolescence is disturbed, particularly if they experience rejection.”

A safe space

The good news is that counselors can help bridge the acceptance gap for LGBTQ youth.

“Counselors can create a safe space by a variety of means,” Hammer says. “It can be as simple as displaying an HRC [Human Rights Campaign] ‘equal’ sign in their office or a small rainbow flag somewhere. I know that sounds minor, but small symbols can signify something to students.”

“It is also a matter of having resources available,” she says. “GLSEN [formerly the Gay, Lesbian and Straight Education Network] has a resource called Safe Space Kit that provides curriculum, activities and also stickers that can be displayed which indicate that your office is a safe space. Additionally, counselors can provide programming that is LGBT inclusive or sponsor organizations like a Gay-Straight Alliance. There are activities or weeks that counselors can help organize, such as No Name-Calling Week, Ally Week and Day of Silence.”

When meeting with students, school counselors can create supportive environments by using language that does not assume a student is attracted to any particular sex, Brown says. “This can let students know that you are open to them sharing that information when they are ready,” he says. “School counselors can also be sure to have pamphlets and information sources that include LGBTQ issues and use these examples if they present to classes. Counselors can also include LGBTQ sensitivity training in any presentation they may give to faculty and staff so that the supportive environment may be spread.”

GLSEN has been tracking the school experience of LGBTQ students since 1999 through its National School Climate Survey. Although the survey has shown an improvement in awareness and acceptance of LGBTQ students in schools, significant harassment and discrimination still exist, particularly in relation to transgender students. The 2015 survey found that 85.7 percent of LGBTQ students heard negative remarks from their peers specifically about transgender people, whereas 65.3 percent heard negative remarks from teachers and other school staff members. The survey also found that 22.2 percent of transgender students had been prevented from wearing clothing considered inappropriate based on their legal sex, while 60 percent of transgender students had been required to use a bathroom or locker room of their legal sex.

In late February, President Trump rescinded a 2016 directive issued by President Obama that ordered schools to allow transgender students the use of bathrooms that match their gender identity. The battle reached the Supreme Court with G.G. v. Gloucester County School Board, in which Gavin Grimm, a transgender boy, filed suit against the Virginia school board alleging that it violated Title IX of the Education Amendments of 1972 by denying him the use of the boys’ restroom. On March 2, in a development indicative of growing support for transgender individuals, 53 major businesses signed on to a “friend of the court” brief in support of Grimm. However, the case ultimately was sent back to a lower court.

School counselors can play a critical role in supporting the rights of transgender students, Brown says. “School counselors can help advocate for and with transgender students through engaging in school policy discussions and promoting fair bathroom, locker room and athletic policies,” he urges. “They can also be outspoken against bullying of transgender students and assist other school professionals with stopping bullying. Importantly, school counselors can also support transgender students simply by using [these students’] identified names and gender pronouns. Although this seems small, many students are not supported in this way, and acknowledging [their] true selves can help foster their development.”

Brown also encourages school counselors to educate themselves about the multiple identities that fall under the transgender umbrella, such as gender-queer (individuals who do not identify with conventional gender distinctions, such as solely male or female, but instead identify with both or neither) and gender-fluid (individuals whose gender identification fluctuates over time).

Hammer adds that the Southern Poverty Law Center and its Teaching Tolerance program provides materials for schools that focus not only on LGBTQ identity issues but also ethnicity and racism. “It is important to remember that our cultural identity, no matter what our affectional/sexual orientation, is made up of so much more,” she says. “The intersection of our ethnicity, age, religious and/or spiritual orientation, gender, affectional/sexual orientation, where we live, etc., are all important factors to consider when working with a client. As a counselor, you should not ignore any aspect of a client’s culture. For example, the intersection of affectional/sexual orientation with a person’s religious and/or spiritual identity can either be a source of support and comfort for someone, or possibly a source of rejection and trauma.”

As always, Hammer says, the most important thing to focus on when working with LGBTQ students is the counselor-client relationship. “Listen to them with respect and treat them with dignity and not as if they are abnormal,” she says. “Let them know that they matter — to you, to their families and to the world.”

Working for a living

One of the hallmarks of adulthood is the ability to support oneself, which typically means going to work, notes ACA member Larry Burlew, whose research specialties include issues around adult development, gay men and career development. However, work can be an uncertain and sometimes hostile place for LGBTQ individuals, Burlew says.

For instance, those who are LGBTQ often have no legal protections against discrimination in the workplace, says Burlew, a counselor educator who is retired from full-time teaching and is currently an affiliate professor at the Chicago School of Professional Psychology in Washington, D.C. There is no federal anti-discrimination protection for LGBTQ individuals, and only 20 states and the District of Columbia prohibit discrimination on the basis of sexual orientation or gender identity.

“It’s easy for them to be dismissed from work without necessarily a good reason,” says Burlew, who was also a licensed professional counselor with a small private practice for almost 30 years.

Even if a workplace is not actively hostile, there may be what Burlew calls a “lavender ceiling” — an environment of subtle but pervasive anti-LGBTQ discrimination. So when LGBTQ individuals first enter the workplace or start a new job elsewhere, they are often dealing with a lot of unknowns, he says. As a result, some LGBTQ individuals decide not to come out or be out at work, choosing instead to keep that part of their identities very private, Burlew says. For LGBTQ individuals, this can require a delicate balancing act between developing and keeping social workplace connections and not fully revealing who they are, he continues.

Even those individuals who are fully out at work often still find themselves managing perceptions, Burlew says. “I think that LGBTQ workers get very creative about how to be successful. When you get to an organization, you get creative about how to present who you are in a way that is acceptable to fellow workers,” he says. “[The question becomes], how do you introduce it in conversation?”

LGBTQ workers also have to determine how they will handle microaggressions, Burlew says. He adds that he has been in situations in which he had to decide whether it was safe to address certain comments and jokes that disparaged the LGBTQ community.

Concerns about how they might be perceived can even influence professional choice for LGBTQ individuals. “I’ve had [clients] throughout the years such as gay men who wanted to go into, say, construction and had fears about that,” Burlew says. He would have these clients visualize going to work in the environment that they feared and imagine how they would be received. Then he would talk with these clients about their fears and explore possible scenarios to help them build skills for dealing with problematic situations.

Burlew uses the example of a gay man working in project management at a construction site who hears that some of the workers have been making fun of him when he isn’t around. What are this man’s options? He has to decide whether he feels safe trying to change the environment (a process called an active adjustment) or if he will choose to change himself instead (a reactive adjustment).

In the case of an active adjustment, Burlew and the client would discuss the potential consequences of trying to change the workplace. They would then work on how to use assertive communication to address the problem. This might include having a conversation with the men making the jokes and saying something such as, “I’ve heard that you don’t want to work with me, and I was just wondering if it has anything to do with me being gay?” Burlew would help the client develop assertive communication skills through role-play and practicing what he wanted to say. Burlew and the client would repeat these techniques until the client felt comfortable addressing the problem on his own.

In the case of a reactive adjustment, Burlew would help the client reduce his stress level through systematic desensitization. He would do this by having the client talk about the incident in which he experienced the most stress. They would continue to “practice” the incident until the client could imagine the situation without feeling an undue level of stress.

Burlew and the client would also talk about avoiding work scenarios, if possible, that caused the client the most stress. If avoiding these situations was not possible, Burlew would help the client evaluate how to move forward by asking questions. Did the client need to stay in the position for his career? If so, for how long? Were other alternatives possible, such as pursuing additional education or staying with the company but taking another position?

Relationships and family

Life isn’t just about work, of course, but also about personal connections and family.

Young adults can sometimes struggle to establish intimacy, and Burlew says this can be even more of a challenge for LGBTQ individuals because they are often still trying to sort out who they are. They may not be fully out, even to themselves, he explains, which can delay establishing relationships. Then, as these young adults begin making connections in the LGBTQ community and start dating as LGBTQ individuals, additional challenges can arise.

“In addition to the bountiful issues that face heterosexual, cisgender couples, LGBTQI+ couples face [other] stressors from being marginalized,” Ginicola says. “Experiencing bias incidents, trauma and rejection from loved ones can add incredible stress to a relationship. It can be particularly traumatic to have people who are supposed to unconditionally love you — parents, family and your closest friends — disapprove of or reject your partnership while celebrating heterosexual relationships with showers, weddings and family pride.”

Problems can also arise if partners have different degrees of “outness.” As Ginicola explains, “If one person in the relationship is fully out to others, and one partner is not, this can cause additional struggles within the relationship, where one person may feel invalidated.”

In such cases, it is important for counselors to explore the reasons that one partner prefers to remain in the closet or less out, she says, paying particular attention to how each partner’s coming-out experience may have differed. The partner who fears being fully out may have come from a culture in which being LGBTQ was not just taboo but also put the individual at high risk for violence. Or the person may have grown up in a religious background that stridently disapproved of LGBTQ individuals, Ginicola explains. Counselors should also encourage the out partner to talk about how it feels for the relationship to be “hidden,” Ginicola says. By improving communication, counselors can often help these couples resolve their conflict in a way that works for each partner, she says.

Another area in which LGBTQ individuals and couples face significant barriers is family planning. “In some states and in most international adoptions, same-sex couples cannot adopt,” Ginicola points out. “Therefore, they may have to utilize expensive alternatives, such as artificial insemination or IVF [in vitro fertilization] or surrogacy.”

“Again, counselors should employ affirmative counseling techniques to support these individuals and partnerships,” she says. “Acknowledging the realities and struggles of being an LGBTQI+ couple or relationship is important, as is providing nonjudgmental support and connecting clients to resources that can help them with family planning that is specific to LGBTQI+ couples.”

Taking a toll

As individuals face the various struggles that are unique to being LGBTQ throughout childhood and into adulthood, it can take a significant toll on the body.

“The LGBTQI+ person is under much greater stress than is typical for a heterosexual, cisgender person,” Ginicola says. “If the person has intersectional identities that are also marginalized — ethnic minority, immigrant, differently abled — this stress will be exponentially increased. Although anxiety, depression and suicidal ideation are common as a result of this increased stress across the LGBTQI+ spectrum, the research indicates that each subpopulation experiences different physical and mental health problems.”

“For example,” she continues, “lesbian and bisexual women are more likely to be obese and are more likely to smoke. Gay men are more likely to experience eating disorders, including anorexia, drink excessively and use substances to cope, which impact their physical health.”

In addition to all of this, medical doctors aren’t always cognizant of how LGBTQ health needs might be different from the needs of their other patients, says ACA member Jane Rheineck, a past president of ALGBTIC. For example, she notes, gynecologists often offer lesbians — even out lesbians — birth control.

In addition, LGBTQ individuals often feel uncomfortable or unsafe disclosing in doctors’ offices, Rheineck says, which means that they may delay or even altogether avoid seeking health care. Counselors can help by educating LGBTQ clients about some of the unique risks that they face, but also by providing them with validation, support and empathy for these difficulties, she says.

“Psychoeducation surrounding minority stress, understanding why these negative coping factors are there, [and] recognizing and validating the stress that they experience is crucially important,” Ginicola says. “Cognitive behavior therapy can be helpful in this regard. [It involves looking] at how their inner self-talk and coping skills are moving them more toward their goals or further away.”

Ginicola says counselors can also help clients find LGBTQ-friendly health care through resources such as the Gay and Lesbian Medical Association’s website (glma.org), which has a provider finder.

Being older in a youth-obsessed society is not always easy, but being older and LGBTQ can be even more difficult, Ginicola asserts. Older LGBTQ adults are not only discriminated against in general society but can often find themselves marginalized within the LGBTQ community, she explains. “Therefore, they may experience bias incidents both inside and outside of their community,” she says.

Older LGBTQ adults were more likely to have come out in a hostile societal environment, says Christian Chan, a former family counselor and current doctoral candidate in counseling at George Washington University in Washington, D.C. This history of intense stigma and marginalization puts older LGBTQ adults at even greater risk for mental health issues such as depression and substance abuse, he notes. In addition, at a stage in life when health care issues may necessitate the need for long-term care, older LGBTQ adults are more likely to have a difficult time securing it because retirement communities and nursing homes often discriminate against those who are LGBTQ, Chan and Ginicola say.

Counselors can help this client population, but only if they are aware of the issues, says Chan, who serves as the student trustee for ALGBTIC and the member at large for outreach and advocacy for the Association for Adult Development andAging, a division of ACA. He emphasizes the need for further training in counselor educator programs and beyond.

“[We should] focus on extending training on how to discuss sexuality, affectional [orientation] and gender identity in conversations and meaning-making around self-disclosure and coming out,” says Chan, who is also president of the Maryland Counseling Association. “It appears to me that many counselors are unsure about how to navigate these questions at large in counseling, which makes the counseling less culturally responsive to older LGBTQ adults.”

Chan urges individual counselors to help their LGBTQ clients build social support networks. “This is especially important in the sphere of redefining family for older LGBTQ adults,” notes Chan, who adds that the concept of family may need to be extended beyond the traditional definition for these clients.

Chan also points counselors toward organizations such as Services and Advocacy for Gay, Lesbian, Bisexual and Transgender Elders (sageusa.org) and the National Resource Center on LGBT Aging (lgbtagingcenter.org) that specialize in helping older LGBTQ adults. AARP’s website (aarp.org) also contains a significant amount of information on LGBTQ issues.

Transgender individuals walk a particularly difficult and dangerous road throughout the life span, confronting widespread misunderstanding and discrimination and an extremely high likelihood of becoming victims of violence, Ginicola says.

“Trans persons, particularly trans women of color, face incredible bias both inside and outside of the LGBTQI+ community,” she says. “When a person transitions, their family and partner must transition with them, which may not always be possible. For example, a trans male, designated as female at birth, may have been in a relationship with a lesbian. When he transitions to male, his partner may experience identity issues and difficulty in accepting a male as her partner. Transitioning can bring a transgender person such relief in terms of finally being able to be their authentic self, but at the same time, they are likely to experience rejection, bias incidents and discrimination within their personal and professional lives. This is why trans persons are also at the highest risk for suicide.”

Ginicola says that affirmative counseling is crucial to transgender — and, indeed, all LGBTQ — clients. “Affirmative counseling is truly about validating an identity,” she says, “while understanding the realities of being marginalized, building coping skills, connecting clients to affirming communities and making cultural accommodations.”

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ACA Illuminate

The American Counseling Association will be holding Illuminate, an innovative counseling symposium focused on serving the needs of the LGBTQ community and those who work with members of this community, from June 8 to 10 in Washington, D.C.

Illuminate is a passion project for ACA President Catherine B. Roland, who has made LGBTQ issues one of her presidential initiatives. “The inspiration [for Illuminate] occurred many years ago and became real right after I was elected ACA president,” Roland says. “I knew that the marginalized population of the LGBTQ community, and the diversity and multiple identities within it, should be a focus of mental health treatment.”

Roland’s goal for Illuminate is to help more counselors and counselor educators gain a greater awareness of the needs of the LGBTQ community and learn how to offer the best care. She also hopes that the symposium will generate additional specific strategies for working with the population, families and career aspirations of LGBTQ adults across the life span.

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Where do we draw the line between “identity”, and mutilating the body to make it into a different gender? Where do we draw the line when young children are taking hormones and having surgery to similarly permanently alter their bodies?